IOGP fatal incident report

Incident description:

A water injection filter was leaking from the filter outlet flange. In order to perform the repair job, the water injection well was closed and isolated. A Contractor crew, instructed by a Company representative, tightened the flange and the leakage was stopped. Nevertheless, since a drainage valve was also noted to be in bad condition, the Contractor crew decided to replace it and to use this drainage valve to replace the vent valve which was also corroded, without any technical evaluation of internal and external conditions. After this intervention, the water injection well was re-opened and the injured Person (IP) was asked to remain onsite to monitor the situation. A few hours later, the vent valve started to leak. For this reason, the IP climbed the top of the water filter trying to install a plug. At this point the vent valve departed from its position and hit the IP in the face. He then fell to the ground.

What Went Wrong:

Departure of the vent valve from the water filter because of the pressure in the line. - Incorrect behaviours implicitly tolerated. - Poor PTW management: it was not opened for the activity while field personnel assumed that it had been opened by office personnel. - High pressure not recognised as hazard. - MoC procedure not applied in a situation that clearly was demanding for this. - IP not contractually entitled to carry out the activity leading to the event. - IP was standing on the filter in poor balance at about two metres high, without any fall prevention system nor any kind of PPE for work at height. - IP put himself over the equipment in the potential “line of fire”, because of the working condition.

Corrective Actions:

Isolation and Lock Out. Tag Out procedure must be applied before starting maintenance activities: - Implement fall prevention measures, e.g. working basket for work at height and also consider applying fall protection measures (i.e. safety harness) as an additional barrier. - Do not work over the equipment in the potential “line of fire”. - Apply PTW and MoC procedures in situations that clearly are demanding for these. - Guarantee that the most critical jobs are fully supervised and not carried out alone.